Medicare-Medicaid Plan (MMP) Enrollment -- Overview

Sharon Donovan Medicare-Medicaid Coordination Office (MMCO)

July 18, 2013

• Overview of final Enrollment Guidance – Enrollments

• Passive • Voluntary

– Cancellations, Disenrollments, and “Opting Out” • Beneficiary-initiated • Involuntary

– Emphasis on policy/procedures • With notes on operations

Agenda

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• References in each slide’s header

- "§" refers to section number in the Enrollment

Guidance itself

• “Days” means calendar days

References Cited

• States will be responsible for enrollment process – “State” includes State’s enrollment broker – In limited instances and with CMS approval, may delegate

certain functions to Medicare-Medicaid Plans (MMPs), but cannot delegate

• Passive enrollment • Collecting health-related information during voluntary enrollment

process • Involuntary disenrollments

– Exceptions – 1-800-MEDICARE will process requests for disenrollments, cancellation of disenrollments, and opt-outs

• They will refer all other enrollment-related requests to the State • Guidance is national level

– State-specific variations will be in Appendix 5

Overall Framework

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• States need to send enrollment-related notifications to CMS’ MARx enrollment system

• Will use CMS-designated enrollment vendor (Infocrossing) – If State delegates any enrollment functions to an

MMP, that MMP must also use Infocrossing

Operational Notes

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• CMS system processes transactions daily – Provides a daily transaction reply report (DTRR)

• Basic flow of enrollment transactions:

CMS Transaction Processing

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MMP enrollment file submission to

Infocrossing’s SFTP server

Infocrossing (validates the file

format and converts into a MARx format)

State(or MMP)

CMS (processes enrollment and sends DTRR to Infocrossing)

Infocrossing (distributes the

DTRR to State or MMP)

MMP Enrollment (State and MMP

send out enrollment notices and materials)

Passive Enrollment

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• Have Medicare Part A and Part B • Are eligible to enroll in a Medicare Part D plan • Have full Medicaid eligibility • Permanently reside in MMP service area • Meet additional State-specific inclusion criteria

(Appendix 5) Note: If State permits individuals with ESRD to enroll, see additional procedures in §30.2.4

Identify Passive Enrollees (§§ 10, 30.1.4.A)

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• Are enrolled with a PACE organization • Have employer or union sponsored health or drug

coverage – see §30.2.6 • Have a Medicare Retiree Drug Subsidy (RDS) – see

§30.2.5 • Are confined in a correctional facility • Have opted out from passive enrollment or Part D auto-

enrollment • Meet additional State-specific exclusion criteria (Appendix

5)

Excluding Individuals from Passive Enrollment (§30.1.4.A)

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• Infocrossing provides a Medicare eligibility query service to confirm Medicare entitlement status

• State may also use: State Medicare Modernization Act (MMA) Response –

batch process Territory Beneficiary Query (TBQ) Response – ad hoc

query option – batch process MARx online query –State who have been given access

to CMS MARx system can see real-time Medicare data (but only one Medicare record at a time)

Ways to Check Medicare Eligibility (§§ 20.1, 30.1.4 F., 30.2)

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States may send an initial outreach notice to potential enrollees

• Introduce the program • Identify resources, e.g., State/enrollment broker,

Ombudsman, SHIP, ADRC

Optional Initial Outreach Notice (§ 30.1.4.B)

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• State attempts to assign beneficiaries to an MMP that best meets their needs, based on more frequently and recently used providers

– If person already enrolled in Medicare Advantage plan or Medicaid Managed Care Organization that also offers MMP in same service area, State may enroll person in that MMP

• May not passively enroll individuals in MMP with poor past performance in Medicare

Assign to MMP (§30.1.4 B)

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• 60 days before effective date – State notify beneficiary of passive enrollment,

including: MMP assigned Other options How to opt out of passive enrollment Who to contact for more support and information

State Notifies Beneficiary (§30.1.4.D)

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• 60 days before passive enrollment effective date, State

– Sends enrollment file to Infocrossing to send CMS » Enrollment source code = J (State-submitted passive enrollment) » Application date

• If passive effective date is January 1, use October 14 • Otherwise, use date of transaction submission to CMS

» See MMP Technical Manual for additional details

• Submits 834 Benefit Enrollment and Maintenance file to MMP, with address

State Submits Files to CMS and MMP (§30.3)

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• Infocrossing performs: File format check and data validation

Sends back rejected records to States that have errors or mismatchs for correction and re-submission

Eligibility check against the Medicare Beneficiary Database (MBD) Sends back records determined ineligible to States

Once the record passes these checks, Infocrossing creates an enrollment transaction (TC 61) in MARx format and send it to CMS

Infocrossing Batch Transaction Processing

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• CMS returns a DTRR to Infocrossing – Infocrossing sends to State and MMP simultaneously

• DTTR has Transaction Reply Codes (TRCs) indicating if record was processed successfully, or rejected

– Accepted: State and MMP should update their records, as appropriate – Rejected: TRC indicates why enrollment could not processed and whether

an action is needed by State or MMP

• Infocrossing also updates their Web Portal to allow State or MMP users to view the DTRR

• For details on DTRR file layout and valid values, please see PCUG Main Guide and Appendices

CMS Processing and Response

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• Transaction Reply Code (TRC) – Refer to TRC table (page I-2) of the PCUG Appendices

» Shows recommended action, to either • Take corrective action and re-submit the transaction, or • Understand why enrollment cannot be processed based

on reason shown in TRC

• Required beneficiary notices – See Appendix 4 for required notices and timeframes

Transaction Rejects

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• 4Rx Data – Beneficiary-specific billing codes generated by each MMP

• State may opt to submit 4Rx data to CMS with enrollment transaction

– But State would have to obtain 4Rx data from MMP prior to sending an enrollment file.

• State may want instead to delegate sending of the 4Rx data to MMPs

– If DTRR shows no 4Rx data, MMP must submit 4Rx data to CMS directly within 72 hours

– Transaction Code 72

MMP submits 4Rx Data (§30.1.4.J.)

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• 30 days before effective date – State send reminder letter (Exhibit 5) – MMP send welcome letter (Exhibit 5a) and

• MMP-specific Summary of Benefits • Formulary • Provider and Pharmacy Directory • Proof of health insurance coverage

State and MMP Notify Beneficiary (§30.1.4.D., 30.4.1.B)

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• No later than the last calendar day of the month before passive enrollment effective date, MMP sends

• Single ID card to access all covered services • Member Handbook (Evidence of Coverage)

MMP Sends Remaining Material (§30.4.1)

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• Passive enrollment is coordinated with LIS auto-enrollment and reassignment

– Ensure enrollment change happens only once per benefit year that is not initiated by an eligible individual

• The only circumstances in which a beneficiary may be passively enrolled more than once in the same year are:

– when MMP contract terminates, or – when it is determined that remaining in the MMP poses potential

harm to members

Coordinating Passive Enrollment with other CMS activities (§30.1.4)

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Voluntary Enrollment

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• Individual requests enrollment via – Telephone – Internet – Paper enrollment form

Note: State may prefer other enrollment request mechanisms over paper form, but State must accept paper enrollment requests if received by mail, in person or by fax.

• State must provide the evidence of the enrollment request to the beneficiary , e.g., – copy of completed enrollment form – confirmation number (for telephonic or on-line enrollment)

• State must ensure enrollment request is “complete” – Appendix 1 lists all the elements needed

• Optional – State may send acknowledgement letter (Exhibit 3) – Within 10 days of initial enrollment request – But, may wait until next steps and combine with other notices

Individual Requests Enrollment (§§ 30.1.4, 30.2, Appendix 1)

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• Check available systems to ensure the individual meets the basic MMP eligibility

– E.g., State systems, Infocrossing eligibility check system, MMA Response file, TBQ response file, or MARx online query

– If any information is missing but State or CMS system provides the missing information, must use that source to complete the enrollment application.

• Health related questions may be asked during the enrollment request

– To support successful transition of care – Not to be used to determine if an individual is eligible to enroll in an MMP,

except if individuals with certain conditions are excluded from enrollment – Information collected must be securely and electronically forwarded

State Determines MMP eligibility (§§ 10, 30.2, 30.2.2, 30.2.3, 30.4.1)

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• State notifies beneficiary enrollment is confirmed – If acknowledgement notice sent, send enrollment confirmation notice within 10

calendar days of the receipt of DTRR (Exhibit 7) – If acknowledgement notice not sent earlier, then send combined

acknowledgement/confirmation notice within 7 calendar days of the receipt of DTRR (Exhibit 4)

• If CMS rejects the enrollment transaction, State must send a notice of rejection within 7 calendar days of receiving the DTRR (Exhibit 10)

When Enrollment Is Complete (§ 30, 30.4.2)

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• “Incomplete” means missing required information – See Appendix 1

• State has 10 days from initially receiving request to – notify the beneficiary the request is incomplete and – request the needed information (Exhibit 6, or may request information verbally)

• Beneficiary has 21 days to provide requested information • If received within that timeframe and enrollment can be considered complete,

state has (from date of receipt) – 7 days from date enrollment considered complete to submit transaction

to CMS – 10 days from receipt of DTRR to notify beneficiary enrollment is

confirmed • If acknowledgement notice sent, send enrollment confirmation

notice (Exhibit 7) • If acknowledgement notice not sent earlier, then send combined

acknowledgement/confirmation (Exhibit 4)

If Enrollment Is Incomplete (§30.2.2)

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• Enrollment denial happens before transmitting enrollment file to CMS

• Two reasons for denial: – Determined ineligible – Expiration of the timeframe (21 days) for receipt of requested additional

information

• Timeframe to send denial notice – 10 calendar days from: – Receipt of an enrollment request, or – Expiration of the 21-day timeframe for beneficiary to provide missing

information

• Denial must be in writing (Exhibit 9)

Denying An Enrollment Request (§§ 30.2.2, 30.2.3)

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• Application date – date request is initially received – See Appendix 2 for details

• Effective date is usually the 1st of the following month of the receipt of the completed enrollment request.

– Exception for those whose MMP eligibility is further in the future – Effective date cannot be prior to application date – Effective date rule holds even if request timeframes push determining if enrollment

is complete until after effective date » E.g. May 20 – Beneficiary requests enrollment (so effective date is June 1);

May 30 – State sends notice requesting missing information; June 20 – Beneficiary submits missing information. Effective date is still June 1.

• State may establish a voluntary enrollment cutoff date no more than 5 calendar day before the end of the month.

– The effective date for those who submit a voluntary enrollment request after the cutoff date will be the first day of the second month after receipt of the request.

Application Date and Effective Date (§§ 20.1, 30, 30.1.1, 30.2 I., 30.2.3, 30.4.1, Appendix 2)

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• Same as passive enrollment: • Enrollment File submission to Infocrossing • File format/Data Validation, Eligibility Check, and TC 61 to CMS • MARx processes TC 61 and returns a DTRR to State and MMP via Infocrossing • State and MMP update their enrollment records; State and MMP sends

enrollment notices/materials to the beneficiary. • If no 4Rx data present in the DTRR, MMP promptly submits TC 72 to CMS via

Infocrossing • State and MMP receive another DTRR that TC 72 has been processed by

CMS and updates their system. • Rejects: DTRR has TRC indicating why enrollment was not processed and what

action is needed (See page I-2 of the PCUG Appendices) • See also MMP Technical Manual

Voluntary Enrollment Transaction Flow

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• MMP must provide the following materials by end of the month before the effective date

– Exception – if DTRR received less than 10 days before the end of the month, then MMP has 10 days from receipt of DTRR to send

• Required materials: – Formulary – Provider and Pharmacy Directory – Member ID card – Member Handbook (Evidence of Coverage)

MMP Sends Plan Materials (§30.4.1 )

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Cancellation, Disenrollment, and

Opt-Outs

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• Beneficiary may cancel an enrollment (or disenrollment) request by contacting the State any time prior to the effective date of enrollment (or disenrollment)

– State may require a cancellation request in writing for their records – But must not delay and must accept any verbal requests to cancel a

voluntary enrollment, disenrollment, or opt out

• Medicare will attempt to automatically return person to Medicare health or drug plan in which the person was previously enrolled

Cancellation Request (§ 30.1.4, 50.2, 50.2.2)

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• Cancelling passive enrollment -- within 10 calendar days of receiving request

– Submit to CMS via Infocrossing: » Enrollment cancellation transaction (TC 82), and » Opt-out transaction (TC 83)

– Send written notice to beneficiary (Exhibit 11)

• Cancelling voluntary enrollment -- within 10 calendar days of receiving request

– Submit TC 82 (enrollment cancellation) to CMS via Infocrossing – Send written notice to beneficiary (Exhibit 11)

Cancellation Request (Continued)

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• Cancelling voluntary disenrollment – Within 10 calendar days of receiving request

» Submit TC 81 (cancellation of disenrollment) to CMS via Infocrossing » Send written notice to beneficiary confirming request received (Exhibit

18) – Within 10 days of DTRR, send notice to beneficiary confirming re-instatement

in MMP (Exhibit 27) – See also MMP Technical Manual, PCUG Appendices

• Individuals may call 1-800-MEDICARE to request disenrollment from MMP, so would contact them to cancel the request

– 1-800-Medicare will process and submit directly to MARx – States will be notified via DTRR

» Look for TRC 288 on DTRR – Send Exhibit 18 within 10 days of receiving DTRR

Cancellation Request (Continued)

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• Disenrollment are those a beneficiary makes after the effective date of enrollment

• There are two types of disenrollment - Voluntary and Involuntary • An individual may voluntarily disenroll in any month and for any reason by: Enrolling in another Medicare health or Part D plan, including a PACE

organization Enrolling in another MMP Giving or faxing a signed written disenrollment notice to the State/MMP Calling 1-800-MEDICARE Calling the State’s enrollment broker Other State-specific methods as identified in Appendix 5 (if applicable)

Disenrollment Request (§§ 40, 40.1, 40.2)

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• For beneficiary request that is complete – Within 7 days, submit to CMS via Infocrossing a TC 51 (disenrollment transaction)

» Put a “Y” in the MMP Opt Out Flag field (position 202) – Within 10 days, send written notice to beneficiary (Exhibit 14)

• If incomplete, request missing information from beneficiary within 10 calendar days (Exhibit 15)

• Denying disenrollment request – Request is

• Incomplete (and missing information not received after requested) • Made by someone who is not beneficiary’s legal representative

– Send written notice to beneficiary within 10 calendar days (Exhibit 17)

Processing Voluntary Disenrollment

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• If first notified by DTRR » Because person enrolled in another Medicare plan » Because person requested disenrollment directly from 1-800-

MEDICARE – Within 10 days, send written notice to beneficiary (Exhibit 16) – DTRR will include Medicare health or drug plan into which person

enrolled (if applicable)

• Effective date is first day of month after request received

– No early cut-off permitted for beneficiaries to request disenrollments

Voluntary Disenrollment, continued

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• Mandatory disenrollments – Move out of MMP service area (Exhibits 19, 20) – No longer meets MMP eligibility criteria (Exhibit 21, 24) – Death (Exhibit 23) – Contract termination/service area reduction – Beneficiary materially misrepresent information on third party coverage – NOTE: In some cases (e.g., loss of Medicare), State will not send disenrollment

transaction to CMS, but instead be informed via the DTRR of CMS-initiated disenrollment. However, State must still send a letter to the beneficiary notifying him/her of the disenrollment from the MMP.

• Deemed continuous eligibility for short term loss of Medicaid – MMP option – For two months – Must continue to cover all MMP-covered services, even if not receiving Medicaid

capitation payment

Involuntary Disenrollment – Mandatory (§§40.2, 40.2.3.2)

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• Disruptive behavior • Fraudulent information on enrollment request • Abuse of enrollment card

Involuntary Disenrollments – Optional (§40.3)

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• MMP Opt Out – Indicates person should be excluded from passive enrollments for life

of the demonstration – Does not preclude individual from voluntarily enrolling in MMP

• If individual opt-out prior to being in an MMP, submit the opt-out transaction (TC 83)

• When individual voluntarily disenrolls from MMP, State should also set the opt-out indicator

– Submit TC 51 (disenrollment transaction) and indicate a “Y” in the MMP Opt Out Flag field (position 202)

– Send an opt out acknowledgement notice (Exhibit 28) with the disenrollment notice within 10 calendar days

MMP Opt Out Request (§§ 30, 30.1.4 B., 30.1.4 E.)

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Other Resources

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Most common TRCs

Transaction Reply Codes (TRC)

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Enrollment TRCs - Continued

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The following TRCs are the most common disenrollment TRCs to be received by States and MMPs To see a full list of TRCs, See page I-2 (Table I-2) of the Appendices of PCUG

Disenrollment TRCs

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• MMP Enrollment and Disenrollment Guidance

http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMPFinalEnrollGuidance.pdf

• MMP Technical Manual http://www.chcs.org/usr_doc/MMP_EE_Guide.pdf

Additional Resources

• PCUG Main Guide: – http://www.cms.gov/Research-Statistics-Data-and-

Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/PCUG_v70_Main_Guide_Final_03012013.pdf

• PCUG Appendices: – http://www.cms.gov/Research-Statistics-Data-and-

Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/PCUG_v70_Appendices-Final_03012013.pdf

Additional Resources

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Questions?

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• Send enrollment policy and procedure questions to CMS MMCOCapsmodel@cms.hhs.gov

• Send questions related to Infocrossing MCareSupport@wipro.com

(877) 833-3499